Cervical Cancer (Over)Screening in Belgium and Switzerland: Trends and Social Inequalities

Published in "European Journal of Public Health 30(3): 552–557, 2020" which should be cited to refer to this work. Cervical cancer (over)screening in Belgium and Switzerland: trends and social inequalities Vincent De Prez1, Vladimir Jolidon 2, Barbara Willems1, Ste´ phane Cullati2,3, Claudine Burton-Jeangros2, Piet Bracke1 1 Department of Sociology, Ghent University, Ghent, Belgium 2 Institute of Sociological Research, Geneva School of Social Sciences, University of Geneva, Geneva, Switzerland 3 Population Health Laboratory, Department of Community Health, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland Correspondence: Vincent De Prez, Department of Sociology, Ghent University, Korte Meer 5, 9000 Ghent, Belgium, Tel: þ32 (0) 9 264 68 12, Fax: þ32 (0) 9 264 69 75, e-mail: [email protected] Background: Cervical cancer screening (CCS) by means of Pap smears has led to a decrease in cervical cancer incidence and mortality. In the absence of organized programmes, CCS is opportunistic in Belgium and Switzerland. This might result in a high level of CCS overuse, as screening practices do not conform to the recommended 3-yearly screening interval and the target age-ranges (Belgium: 25–64, Switzerland: 20–70). This study aimed to assess trends in CCS uptake and overuse in Belgium and Switzerland and their social determinants, in the light of reimbursement initiatives, which were implemented in both countries. Methods: Data from five waves of the Belgian Health Interview Survey (1997–2013) (N¼11 141) and Swiss Health Interview Survey (1992– 2012) (N¼32 696) were used. We performed Poisson regressions to estimate adjusted prevalence ratios (APR), controlled for socio-economic and socio-demographic characteristics and health status. CCS overuse was opera- tionalized as screening more than once every 3 years and screening above recommended age-range. Results: CCS uptake remained relatively stable over time, with a mean coverage of 70.9% in Belgium and 73.1% in Switzerland. Educational and income gradients were found in both countries. Concerning CCS overuse, women above screening-eligible age showed consistently high screening rates, but screening within the past year declined significantly in both countries, matching the temporal implementation of the reimbursement initiatives. Conclusions: Although no increase in CCS coverage could be established, CCS has become more efficient in both countries as Pap smear overuse at the population level has declined after the implementation of reimbursement measures tackling CCS overuse. ......................................................................................................... Introduction level,4,19 heterogeneous quality,20 psychological distress21 and false positives due to over-diagnosis.15 ncidence and mortality in cervical cancer have declined since the A decline in CCS overuse has been reported in observational and 1–3 I1970s in high-income Western-European countries. These intervention studies in some European countries,16,22,23 both within trends have been linked to the introduction of cervical cancer and outside of the recommended age-range. In order to further http://doc.rero.ch screening (CCS) by means of Pap smears.4–6 Consequently, the picture trends in CCS overuse and to identify potential pathways European Union has recommended 25- to 64-year-old women to to explain a possible reduction in overuse of preventive services, 4 undergo CCS screening on a 3-yearly interval. In organized systems, more research is needed.16 This research offers foothold in this la- eligible women are periodically invited to undergo screening, where- cuna by (i) making a cross-country inquiry into the evolution as in opportunistic systems, the initiative to comply to the screening of CCS uptake and overuse, and (ii) linking the time trends to recommendations is left to physicians and individual women.7 If government initiatives. This is facilitated by comparing Belgium women undergo Pap smears more than once within the recom- and Switzerland. These Western-European countries both rely on mended 3-yearly interval or outside the 25- to 64-year-old target opportunistic screening,4,7,24 and have implemented a similar initia- age-range, this could be considered CCS overuse, which has been tive to limit overuse at national level. However, these countries have found to be more likely in opportunistic systems.4 In the first form different preventive healthcare systems. The Swiss healthcare system of CCS overuse, women within screening-eligible age undergo CCS is more liberal and fragmented between regions than the Belgian 8–13 too frequently. In the second form, past research had identified system which is more uniformly coordinated by the federal govern- 14,15 both women below the recommended age and women above the ment. The Swiss system also relies much more on out-of-pocket recommended age16–18 for screening. CCS overuse entails several expenditure compared to the Belgian one when considering prevent- detrimental aspects, such as low cost-effectiveness at population ive care. 1 CCS overuse has been observed in Belgium since the 1990s,9,25 respondent was screened within the last year (yes ¼ 1, no ¼ 0), and has declined from a 3-yearly average of 1.88 smears per women among women who have been screened within the last 3 years. This in 200026—1.18 smears in 2010–12.27 In Switzerland, it was esti- dependent variable operationalizes our second definition of screen- mated that a screening coverage of 70% is achieved by the 1–1.2 ing overuse based on the screening frequency and understands over- million Pap smears that are taken annually.28,29 Nevertheless, use as screening more than once within the recommended 3-yearly 520 000 smears would be enough to cover 100% of the eligible time frame.30,35 Hence, if women answered ‘yes’ to this question, population.28,29 In both countries, similar policy incentives affecting they were classified in the overuse category. Among the screening CCS overuse were implemented. The Swiss government has, accord- women, if the proportion of women who stated that they were ing to the 1996 Swiss health insurance law, reimbursed one CCS screened within the last year was >33.33% (under the assumption every 3 years for 18- to 69-year-old women.30 More than a decade of an even distribution over the 3 years) we used this as a proxy later, in Belgium, reimbursement was limited to one Pap smear indicator of overuse at the population level (for a detailed outline of every 2 years since 2009, and to once every 3 years since 2013.27,31 this operationalization, see Supplementary material 2). We expect to establish a corresponding impact of these policy measures in both countries. Furthermore, attention is directed towards Independent variables inequalities in screening uptake. Previous research in Belgium and Indicators of interest and covariates were selected based on their Switzerland has found that adherence to CCS guidelines is related to 7,34 the individual’s education, financial situation and socio- potential association with CCS, as indicated by previous research. demographic profile.4,7,32 Women with the lowest probability of We included the following indicators of interest: education, monthly partaking in CCS generally have a lower educational attainment, a household income, employment status, age, nationality and urban- lower household income, an older age, no partner and live in a rural ization. To control for known associations with CCS, we took into area.4 These disparities are shown to be persisting over time.7,33,34 account the following covariates: having a partner, self-rated health, smoking, body mass index (BMI) and having visited a physician Accordingly, we expect social inequalities to be consistent—both for 7,36–38 CCS uptake and for CCS overuse. within the last 12 months (for an operationalization of these In summary, this study aims at assessing the prevalence and trends variables, see Supplementary material 3). in CCS uptake and CCS overuse in Belgium and Switzerland, in the light of governmental reimbursement initiatives. Furthermore, it Statistical analyses builds on previous research concerning the social gradient in prevent- Prevalence rates of CCS uptake and CCS overuse were reported ive health behaviour by examining whether manifestations of socio- using weighted proportions and were stratified by year. Socio- economic inequalities are comparable in Belgium and Switzerland. economic inequalities in CCS uptake and CCS overuse were examined by estimating adjusted prevalence ratios (APR) and their corresponding 95% confidence intervals (CI) using Poisson regres- Methods sion models. Robust variance estimators were used to make sure that Sample the errors were not heteroskedastic. Models were adjusted for the above-mentioned independent variables. Survey wave was included Data used for this study were obtained from the Belgian Health in our models as a continuous variable to take fluctuations over time Interview Survey (BHIS) and the Swiss Health Interview Survey into account. A detection for multicollinearity among socio- (SHIS). Both cross-sectional surveys contain five waves: 1997, economic variables using variance inflation factors showed no 2001, 2004, 2013 for Belgium; and 1992, 1997, 2002, 2007, 2012 issues. Employment status was not included in the model for the for Switzerland. For the BHIS, a random multistage probability 65–75 years old due to too little variation across categories. Trends sample was drawn

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